ANC: Diversion or Real Opportunity to Achieve Better Outcomes?
This post is part of our “Continuum of Care” blog series hosted by the Maternal Health Task Force
What some propose
Most maternal and newborn deaths happen around the time of labor and delivery, so program effort should focus on ensuring delivery with a skilled birth attendant.
Why it is wrong
By this logic, if our concern were deaths due to heart attacks and stroke, we would be arguing to concentrate effort on ambulance, emergency room, and ICU services, rather than an approach that would also give attention to underlying causes, e.g. smoking, obesity, and hypertension.
Is it true that there’s little impact from ANC?
That all depends on what happens during the ANC visit. If there is little attention to appropriate content, there’s little reason to expect much benefit. But if getting ANC means that pregnant women in malarious areas sleep under treated nets and receive intermittent presumptive treatment, risk of bad pregnancy outcomes can be significantly reduced. Likewise, particularly in settings where many deliveries still happen at home in unhygienic conditions, the otherwise devastating risk of newborn tetanus can be largely eliminated if the mother receives tetanus toxoid during pregnancy. The impact doesn’t stop there. Anemia and associated fetal growth restriction can be much reduced by iron-folate supplementation. Delivery in a health facility and timely care-seeking for complications during pregnancy, or at the time of childbirth, can be increased if appropriate counseling is given during ANC. Similarly, the probability of adoption of key newborn care practices—like early initiation and exclusive breastfeeding—can be increased through good ANC counseling.
If ANC can make such a difference, why doesn’t it get more attention?
The short answer: history. Until about 20 years ago, the emphasis in ANC efforts was on “risk stratification”. The idea was that ANC would be used to identify pregnant women at higher risk, e.g. teen mothers, women who’d had many pregnancies, and women with past histories of complications of pregnancy or childbirth. These women were then to be referred to higher level health facilities for care. As a strategy, however, this didn’t work. Most of those identified as “high risk” ended up having normal deliveries and most of those developing complications had been classified as low risk. This has contributed to the perception that ANC is not useful.
In the late 1990s, a multi-country study showed that on most endpoints an abbreviated 4-visit protocol gave comparable results to a more conventional protocol, entailing a larger number of visits (although subsequent analysis actually showed a higher risk of perinatal mortality under the 4-visit protocol). An antenatal package based on the protocol used in the study was then promoted, under the rubric of “focused ANC”. This did include guidelines on timing and content of the visits. However, what was monitored was the proportion of women getting 4 or more ANC visits, not the content of those visits. Not surprisingly, then, it has been number of visits received that has been the main focus of program effort.
Currently, the World Health Organization is doing a thorough review of ANC and is expected to develop new guidelines. The time is right to bring new attention to ANC.
How can we do a better job on ANC?
There are specific elements of ANC which have good evidence for reducing risk. Many are quite simple and can be provided by peripheral level health workers like auxiliary nurse midwives. They can be provided through health posts and outreach services. But it is the actual content or substance of care that provides benefit, not merely having contact with a health worker. Program focus needs to be on actual content. On the principle that “what gets measured gets attention,” we need to make the content of care the focus of our routine monitoring.
Bottom line
ANC can make a big difference—but contact alone will not do it. Having succeeded in getting the pregnant woman in the front door, now we need to ensure she gets what she needs.